Promoting Integrated Approaches to Reducing Health Inequities Among Low-Income Workers: Applying a Social Ecological Framework
Nearly one of every three workers in the United States is low-income. Low-income populations have a lower life expectancy and greater rates of chronic diseases compared to those with higher incomes. Low- income workers face hazards in their workplaces as well as in their communities. Developing integrated public health programs that address these combined health hazards, especially the interaction of occupational and non-occupational risk factors, can promote greater health equity.
We apply a social-ecological perspective in considering ways to improve the health of the low-income working population through integrated health protection and health promotion programs initiated in four different settings: the worksite, state and local health departments, community health centers, and community-based organizations.
Examples of successful approaches to developing integrated programs are presented in each of these settings. These examples illustrate several complementary venues for public health programs that consider the complex interplay between work-related and non work-related factors, that integrate health protection with health promotion and that are delivered at multiple levels to improve health for low-income workers.
Whether at the workplace or in the community, employers, workers, labor and community advocates, in partnership with public health practitioners, can deliver comprehensive and integrated health protection and health promotion programs. Recommendations for improved research, training, and coordination among health departments, health practitioners, worksites and community organizations are proposed.
Overview of article
- Working conditions, both physical and organizational, can influence what are commonly thought of as personal health choices. Employers, workers, labor and community advocates, in partnership with public health practitioners, can deliver comprehensive and integrated health protection and health promotion programs
- This article applies a social ecological framework (SEF) to address the needs, challenges, and existing opportunities to create more integrated programs that consider the interface between health protection and health promotion with a focus on improving the health of the low-income working population. The SEF examines the ways in which multiple levels of influence can impact health outcomes including at the intrapersonal, interpersonal, institutional, community/society, and policy levels of influence. The goal in this study is to examine how better integration might be achieved at these multiple levels of influence through programs initiated in each of four settings: the worksite, state and local health departments, community health centers, and other community-based organizations. Findings from each category are outlined below
Methods of article
- This study applies a social-ecological perspective in considering ways to improve the health of the low-income working population through integrated health protection and health promotion programs initiated in four different settings: 1) the worksite; 2) state and local health departments; 3) community health centers; and 4) community-based organization
- The worksite: Traditionally, worksite health programs have either addressed lifestyle habit (e.g., cigarette smoking) or workplace environmental conditions (e.g., chemical exposures); these are rarely combined as part of an integrated program. Worksite health promotion (WHP) programs typically focus predominately on addressing personal “lifestyle” through education and screening activities aimed at increasing individual workers’ awareness of personal risk factors and suggesting strategies to modify health behaviors. Some have also involved institutional changes in the workplace to promote healthy behaviors, such as providing exercise facilities. Most WHPs do not attend to the larger social, economic and political context that influences health behaviors, work and community environmental conditions, and access to jobs
- State and local health departments: The state and local public health infrastructure can provide many points of access to reach underserved worker groups with information about health and safety risks, and with strategies to control hazards, provide occupational health services and provide information about legal rights. There is renewed recognition of the need for systematic institutional or organizational changes to improve health and new opportunities for integrative approaches – both programs and policies – to improve the health of low-income workers
- Community health centers: Community and Migrant Health Centers (C/MHCs) are direct-care providers serving the poor (including the working poor), the uninsured, the homeless, immigrants and refugees, and migrant and seasonal farmworkers, among others. In 5 C/MHCs in Massachusetts, over 1400 working or recently unemployed patients completed a short, anonymous survey. 21% reported experiencing a work-related injury, illness, or other health problem during the previous year, yet 39% of those experiencing a work-related health problems had never heard of workers’ compensation and 63% had never heard of the Occupational Safety and Health Administration (OSHA). In addition, several model programs have been developed to assist primary care providers (PCPs) in providing more comprehensive care by better integrating risk factors related to the work environment through specialty consultation programs and by providing easy access to information through toll free hotlines. For example, the New York State Occupational Clinic Network, funded through the state worker’s compensation fund, provides consultation to healthcare providers treating patients with potentially work-related illnesses and injuries and also assists professionals and patients to deal with the workers’ compensation system
- Community health workers: Community Health Workers (CHWs) are increasingly used throughout the US to reduce health inequities. CHWs assist people in receiving the care they need, give counseling and guidance on health behaviors, advocate for individual and community health needs, and provide some direct services such as first aid and blood pressure screening. The CHW model is another application of the SEF: as peer mentors, community health workers reach workers and their families to provide information that influences both intrapersonal and interpersonal factors. Most are affiliated with community clinics, and some include issues related to the work environment
- Community-based programs: A community-based participatory approach is useful in reaching many low income workers, especially those workers whose employers are unwilling or unable to address occupational safety and health issues or for workers who may feel intimidated at the workplace. They are also effective in developing education and outreach programs that overcome the cultural, language, and literacy barriers that limit the effectiveness of some workplace training programs
- Overall, this study highlights the following 6 broad recommendations for promoting a more integrated approach to improving the health of low-income workers: 1) Improve access and enhance quality and usefulness of data; 2) Integrate work environmental factors into care at community health centers; 3) Enhance exchange of information and ideas; 4) Provide more integrated public health/occupational health education and training; 5) Engage worker and community participation; and 6) Conduct additional research to test new approaches and to evaluate their effectiveness